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Underwriting and Claims

Who Has Your Back? (or Brain, or Heart, or Whatever is Ailing You)

Who Has Your Back long

You’re the manager of a company’s employee benefits programme and want staff to be protected if they become disabled.


So, you check the key product features of your group disability income insurance – the level of benefit, deferred period, benefit escalation and, most importantly, the price.

In doing so, you may have missed one of the most fundamental features of a group disability product. The unsung hero, and arguably one of the most valuable parts of disability income insurance: case management.

Every day, teams of highly skilled medical staff coordinate rehabilitation and help claimants return to work. This has multiple benefits. For the insurer and the employer, it reduces the cost of a claim, and thus the cost of providing the cover to staff. The employer realises further gains by retaining the skills and knowledge of the employee. Most importantly, the employee can work productively, which has significant social benefits beyond the monthly salary.

There are disabled employees who cannot work again. For them, the long-term financial protection of disability insurance is critical. But for those who can work, the case managers are a lifeline. The following examples help illustrate this. These are based on real cases, but details have been withheld for confidentiality.

Case 1: Ms A

Claimant Details: A woman in her early 40s
Occupation: Department manager for a large clothing retailer

 

Scenario

One morning Ms A woke up and could not remember who or where she was. She was diagnosed with global amnesia and booked off work.

Medical Team

Psychiatrist; psychologist

 

Case Manager

The case manager organised an independent occupational therapist (OT) to assist and assess Ms A. She also coordinated the treatment plan, ensuring that the medical team worked together. At the same time, Ms A’s family and employer formed a key part of the recovery. The case manager worked with them to co-develop a return-to-work plan. This included how to accommodate Ms A, as well as a reintegration and training strategy.

During a trial period in which Ms A resumed work, the disability benefit continued to be paid to remove any financial barriers. Simple steps, like having the OT join Ms A at her first day back at work, helped provide valuable support. 

Workplace Accommodation

Relocated Ms A to a store closer to home; flexible and reduced working hours initially; fewer people reporting to her. 

Time off Work

Nine months

Outcome

Ms A recovered and returned to full-time work.

Case 2: Mr B

Claimant Details: A man in his late 20s
Occupation: Financial advisor (with university degree)

 

Scenario

Following seizures, Mr B was diagnosed with epilepsy. He also had a history of depression. Initially he was unable to drive to visit clients, and was despondent. He remained housebound with minimal activity and missed treatment sessions.

Medical Team

Psychiatrist; psychologist; neurologist

 

Case Manager

The case manager coordinated the medical team to develop treatment goals. An Occupational Therapist (OT) was appointed to help with the patient’s functional recovery. The primary aim was to improve his baseline health, ensure his compliance with treatment, and reduce his social isolation.

A Work Conditioning Programme was created: over ten weeks the OT worked with Mr B to build endurance and confidence with clear goals. In addition, cognitive behavioural therapy was needed with a separate psychologist. Finally, to overcome his anxiety related to driving, the case manager (with the psychologist) organised driving lessons.

Workplace Accommodation 

Mr B was slowly reintegrated into the workplace, increasing the number of clients he saw each week. His disability benefit tapered down as his ability to work increased.

Time off Work

Two years

Outcome

Mr B returned to work in full capacity.

Case 3: Mr C

Claimant Details: A man in his early 50s
Occupation: Goods receiver (with Grade 12)

Scenario

Motorcycle accident with multiple severe fractures; sight in one eye compromised; doctor booked Mr C off work for four months.

 

Medical Team

Hospital; physiotherapist; ophthalmologist; company’s occupational health practitioner

Case Manager

Mr C’s rehabilitation was monitored; given concern about returning to a physical job, the payment period was extended. An independent OT was appointed.

Despite the severity of his injuries, Mr C was determined to return to work. This was challenging, as Mr C did not have experience beyond physical occupations, and his extensive injuries threatened his ability to perform his current job.

A plan was put in place to slowly integrate him back into the workplace. The case manager worked closely with the employer and set up regular check-ins between Mr C and the occupational health practitioner.

Workplace Accommodation

Return to work in a partial capacity; building up to full time over a two-month period, with OT visits at work. The disability benefit continued to be paid during this period.

Time off Work

14 months

Outcome

Mr C returned to his own occupation.   

 
These cases highlight that disability insurance is not just about financial benefits. Without the support and coordination from case managers, these employees might not have returned to work. Although not every case requires intervention as intense as illustrated here, less-severe cases also benefit from support and rehabilitation.

It’s also evident from these examples that case managers need to adapt their focus, depending on the case. They also need to consider a more holistic view of a person when trying to craft a return-to-work programme. Psychosocial factors, such as the employee’s motivation, play a far greater role than often assumed. In Case 2 above, Mr B’s lack of self-belief and anxiety outweighed his physical ability to do his occupation. By contrast, in Case 3, only considering Mr C’s medical condition would have led to the conclusion that he was permanently unable to work – ignoring his internal motivation and social support.

To help case managers triage cases, RGA has developed Morgan™. Morgan™ is our intelligent duration management system – encompassing both a philosophy and supporting software. By considering the medical condition, employment context, and various psychosocial factors, Morgan™ calculates a rating (“mScore”), which can be used to prioritise or flag high-risk cases. One of the key benefits of Morgan™ is that it also helps guide the best approach to take with each claimant. In Case 3 above, the case manager’s role would be more supportive relative to Case 2, where far greater extrinsic motivation was required.

So, when evaluating the value of disability insurance, consider more than the product and the price. Consider the team waiting to support employees in the event of a health crisis – a team that has their back; a team that could even help them work again.

First published in FAnews August 2018 edition.

The Author

  • Neil Parkin
    Chief Pricing Actuary
    RGA South Africa

Summary

When evaluating the value of disability insurance, is it time to consider more than the product and the price? RGA's Neil Parkin explores the importance of case management in the EMEA Quarterly Newsletter.
https://www.rgare.com/docs/default-source/marketing/emea-quarterly-sept2018/welcome.html
  • case management
  • case manager
  • claims
  • claims investigation
  • claims management
  • claims processing
  • disability
  • employee benefit
  • mental health
  • Morgan
  • mScore
  • Neil Parkin
  • Parkin
  • physical therapy
  • rehab
  • rehabilitation
  • return to work
  • RTW